GI Flashcards
Repair of small choledochotomy
Repair with 4-0 or 5-0 PDS
Leave drain
Repair of long choledochotomy
Use a T tube - as big as duct will accommodate
Shoot cholangiogram
30% injury to CBD - repair?
Try to primarily repair
Place t tube remote to injury
Shoot cholangiogram
Repair of esophageal leak s/p dilation for achalasia - 2 cm defect
Left lateral decubitus Posterolateral thoracotomy Take down inf pulm ligament Mobilize distal esophagus Repair in 2 layers - Contralateral myotomy to repair ext 5 cm below GEJ*** Intercostal muscle flap over repair Chest tubes Consider feeding access Leak test
Lap nissen
Open up hiatus by incising phrenoesophageal ligament and mobilize distal esophagus to get adequate intra abdom length (2-3 cm)
During dissection ID and protect vagus nn
Close hiatus
Complete mobilization of fundus and pass posteriorly
Carry out fundoplication over 60Fr bougie approx 2-3 cm in length
EGD to ensure not too tight
Repair of esophageal leak s/p dilation for achalasia - 2 cm defect (distal)
Right lateral decubitus
Left posterolateral thoracotomy - 7th intercostal space, harvesting intercostal muscle flap for future buttress
Mobilize distal esophagus, debride necrotic tissue, vertical myotomy to fully expose mucosa
2 layer repair: vicryl inner, silk outer
Intercostal muscle flap to buttress repair
Perform contralateral myotomy** if underlying achalasia
Leak test through an NG tube passed by anesthesia just proximal to injury and passed into stomach
Irrigate
2 chest tubes
Establish enteral access - J tube
Repair of esophageal leak s/p dilation for achalasia - 4 cm defect
Exclusion and proximal diversion
Can divert proximally via spit fistula - loop
Get thoracic mucocele
G tube for feeds
Normal DeMeester
14.72
3 point suture ligation for bleeding duo ulcer
Longitudinal duodenotomy* Superiorly Medially Inferiorly **take care to avoid CBD** Close duo transversely
Presacral bleeding during APR
Pack off pelvis
Communicate w/anesthesia
Can use abdominal tacks, bone wax etc
4 cm defect of ureter at pelvic brim
Mobilize bladder and ureter
Primary ureteral repair - spatulate 2 ends, repair over double j stent using 4-0 PDS, drain
Can swing it out to the skin as cutaneous ureterostomy or can tie off and plan for perc nephrostomy post op
Workup when suspicious for esoph perf
CXR, EKG
Abx (broad spec - vanco, diflucan, zosyn)
Adherent clot on EGD
Inject epi into 4 quadrants around clot base
Forrest Ia
Spurting hemorrhage
Forrest Ib
Oozing hemorrhage
Forrest 2a
Visible vessel
Forrest 2b
Adherent clot
Forrest 2c
Hematin on ulcer base
Forrest 3
No active bleeding/recent bleeding sx
Endoscopic tx not recommended for which forrest classes?
2c or 3
Stable patient, bleeding gastric ulcer - OR
Ex lap, upper midline laparotomy
Anterior gastrotomy
Oversew ulcer
If refractory disease – can consider truncal vagotomy + antrectomy/pyloroplasty
If oversewing duodenal ulcer, how can you help ID the CBD?
Can insert pediatric feeding tube through the papilla
How to ID GDA if bleeding continues from ulcer despite 3 point ligation
Can be identified superior to duodenum and ligated at origin
Pancreatic cyst - what else are you looking for on CT scan?
Size, where, any nodularity or solid component, is duct dilated, other cysts, calcifications, nearby surrounding structures - is it invading blood vessels, lymphadenopathy, ascites
Pancreatic cyst characteristics to analyze for
Mucin, CEA, amylase, cytology
Pancreatic fistula/leak - options?
IR drainage
Ask GI to place pancreatic stent
Re-operate
Gastrinoma triangle
2nd and 3rd portion of duo
Neck and body of pancreas
Junction of common and cystic duct
Gastrinoma within duodenal bulb
Small duodenotomy
Enucleate
Unable to localize gastrinoma through imaging
Intraoperative US
Can try to do EGD - transilluminate (lesions are submucosal)
Acute recurrent paraesophageal hernia
Relaxing incision on each side of crura
Mesh
ID location of GI bleed - options to localize
C scope CTA Tagged RBC Smart capsule Provocative angiogram
Small bowel bleed - options?
Can try double ballooned enteroscopy
Last ditch effort to localize small bowel GIB
Mini laparotomy
Bring up diverting loop ileostomy
Perform endoscopy
Slipped gastric band
Enter epigastrum through optiview
2 addn ports on either side
Find band, grab silicone tubing and incise directly onto the capsule
Cut clasp, pull it out
Gastric band erosion
EGD following removal of band to assess for leak
UGI in 2 days post op
NGT lavage with clear fluid return - should ask?
If bile was present as well. If not, perform EGD
Heller Myotomy - OR
Liquid diet 48 hrs prior
NGT prior to induction
Triangulate ports to hiatus
Perform hiatal dissection to expose GEJ and anterior esophagus
ID and protect vagus nerve
Divide longit and circumferential muscles to ensure to separate muscle fibers from underlying mucosa
for a length of 6 cm onto esophagus and 2 cm onto stomach
EGD and insufflation leak test
Anterior 180 degree fundoplication
Post op course s/p Heller Myotomy
Esophagram POD1 - if negative for leak, clear liquids
Day 3 - mechanical soft
Adv to regular after 3 weeks if doing well